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Professional Liability Form

Step 1 of 11

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Firm's Full Name(s) – please include any DBA names:*

Please provide your firm’s full, legal name and be sure to include any formal suffixes like “Inc.” “LLC” or “PC.

Address*

Please list your “main office” address.

Street Address

City

State

ZIP Code

Email*

Phone*

Mobile*

Website

Are there any additional locations?*

Yes

No

Additional Location*

Street Address

Address Line 2

City

State

ZIP Code

Who owns the firm listed in question 1? Please list the full name of each owner and show the percentage of ownership (total should equal 100%)

Name*

%*

Please enter a number less than or equal to 100.

Name 2

%

Please enter a number less than or equal to 100.

Name 3

%

Please enter a number less than or equal to 100.

Name 4

%

Please enter a number less than or equal to 100.

% Total (must be 100)

The total ownership percentage for all owners should be 100%

Were any of the principals of this firm principals of previous entities?*

If a principal of the firm shown in Question 1 was the principal of another entity, including a predecessor firm or alternate firm name in use currently or at any time in the past, please list that firm or those firms here. We should discuss whether you would like coverage for that other firm, or for the principal’s involvement in that other firm. Depending on the decision of the underwriter, you may be able to get coverage for that past work.

Yes

No

Previous Entities*

Please list the all previous entities that apply

What was the earliest year the firm above, or a previous entity was formed?*

Is the service your firm provides ‘agency CM’ work, in which you are the eyes and ears of the owner on the jobsite, but don’t have responsibility for construction, site safety and can’t stop the job? If so, please enter the percentage under Construction Management. If no, and you are providing ‘at-risk CM’ work, please indicate this under “Other.”

Type of Projects (must total 100%)

Please list the types of projects you worked on during your last fiscal year. ‘Apartments’ are projects owned by one entity, and rented out to others. ‘Condominiums’ are typically multi-family projects and are considered higher-risk regardless of whether you work for the condo association, developer, or for an individual unit owner. ‘Co-Ops’ should be listed under ‘Other.’

Single Family Residential

Please enter a number from 0 to 100.

Commercial

Please enter a number from 0 to 100.

Condominiums

Please enter a number from 0 to 100.

This project type is considered higher-risk, and some insurers will decline to offer quotes to firms with a high percentage of this work.

Retail

Please enter a number from 0 to 100.

Industrial

Please enter a number from 0 to 100.

Schools/ Colleges/ Universities

Please enter a number from 0 to 100.

Religious

Please enter a number from 0 to 100.

Office Buildings

Please enter a number from 0 to 100.

Apartments

Please enter a number from 0 to 100.

Hospitals

Please enter a number from 0 to 100.

Other

Please enter a number from 0 to 100.

Other – Please describe below*

Your Total*

(total must = 100)

Type of Clients (must total 100%)

Contractors

Please enter a number from 0 to 100.

Developers

Please enter a number from 0 to 100.

Governments

Please enter a number from 0 to 100.

Other Design Professionals

Please enter a number from 0 to 100.

Private Owners

Please enter a number from 0 to 100.

Public Institutions

Please enter a number from 0 to 100.

Other

Please enter a number from 0 to 100.

Other – Please describe below*

Your Total*

(total must = 100)

Staffing: (please include the firm principal(s) in this question. If you have no employees in a category, enter "0")

Licensed Architects:*

Please enter a number greater than or equal to 0.

Licensed Engineers:

Please enter a number greater than or equal to 0.

Surveyors:*

Please enter a number greater than or equal to 0.

Technical:*

Please enter a number greater than or equal to 0.

Administrative:*

Please enter a number greater than or equal to 0.

Gross Billings, including all reimbursable expenses, payments to subconsultants, etc.

Gross billings include all reimbursable expenses, payments to subconsultants, etc. The figures shown in this question should match the gross billing figure on a tax return. If your firm is just starting and does not have historical billings, please provide a billing estimate for the upcoming twelve months. When you make this estimate, I would suggest that you be conservative, yet realistic.

c) What percentage of written contracts are AIA, ConsensusDoc or EJCDC?*

Some insurers will give a credit for your use of industry-standard written agreements.

Please enter a number less than or equal to 100.

d) Does your firm incorporate a limitation of liability clause in its contracts?*

Yes

No

What percentage of your contracts contain a limitation of liability clause less than or equal to $250,000?

e) Does your firm retain subconsultants?*

Yes

No

What percentage of your subconsultants maintain professional liability insurance?

Some insurers will give a credit for your use of insured subconsultants.

Please enter a number less than or equal to 100.

Percentage of your fees paid to subconsultants:*

Please enter a number less than or equal to 100.

f) Does your firm have in-house quality control procedures?*

Quality control procedures need not be written for you to answer ‘Yes’ to this question. If the answer is ‘No’ currently, but you plan to institute quality control procedures, please indicate this to your Maloney & Company, LLC broker.

Yes

No

g) Are plans reviewed before being released?*

Some insurers will give you credit for risk management procedures such as having your plans reviewed before being released. If the answer is ‘No’ currently, but you plan to institute this procedure, please indicate this to your Maloney & Company, LLC broker.

Yes

No

Do you have a professional liability policy in force?*

If you have had a professional liability policy in the past that was discontinued for any reason, please indicate this here.

Yes

No

Name of Insurance Company:*

Limits of Liability:*

Deductible:*

Expiration Date:*

Retroactive Date:*

Premium:*

Are you a named insured on a policy dedicated to one specific project?*

“Project Specific” policies are quite rare. They are typically purchased by a project owner to cover the entire design team on a jumbo project, and last for several years, through design, during construction, then for some limited period of time after construction has completed.

Yes

No

Please decribe the project, its location, its approximate construction value, and indicate the fees you derived from it over the last year:*

Do you have a specific project excess endorsement on your current policy?*

A “Specific Project Excess Endorsement” or “Specific Client Excess Endorsement” is an endorsement to a typical professional liability that bumps the limit of liability on the policy for one specific project or client. If you have such an endorsement on your current policy, please include details below since the quotes we get for you should address this special situation.

Yes

No

Please describe the project and indicate the additional limits required for it:*

Have you ever had a professional liability policy cancelled or non-renewed?*

Yes

No

Please explain the reason for cancellation or non-renewal and when it occurred:*

Claims Information

If you have had any claims made against you in the past five years, please provide details here. The insurers are also likely to want to see the official “loss run” produced by your insurer showing exactly what was paid out, etc.

Have any claims been made or legal action been brought in the past five years against your firm, its predecessor(s) or any past or present principal, partner, officer, director, shareholder or employee?*

If there are any situations out there right now that could be considered a claim circumstance under a professional liability policy, please provide the details here. (A claims circumstance is often described as a situation reasonably likely to give rise to a claim against you.) If the matter has already been reported to an insurer, please include that information as well. As you can imagine, no insurer would be interested in offering you a policy only to have a brewing situation turn into a claim immediately after the policy goes into place, and may decline to cover such a claim if you were aware of the situation and did not disclose it on your application. If you have a policy in place, you should consider submitting any claim circumstance to your current insurer to minimize the risk of having your old insurer decline to cover the claim because it wasn’t made the during policy period and your new insurer decline to cover it because was it was not disclosed on the application.

Yes

No

Claim circumstance*

Please provide the following information for each claim circumstance in the Notes section below.

• Date reported to insurer• Claimant

• Name of project• Allegation/nature of situation

• Date of incident• Demand/amount of damages (if known)

As an authorized representative of the firm or the individual applying for coverage, by checking this box I hereby warrant that the statements and representations made in this application are true and complete. I acknowledge that the information I have provided will be deemed material to the acceptance of the risk assumed by the insurance company in the event an insurance policy is issued.*